[Question #1129] Risks with Escorts

99 months ago

Hello Doctors,

I’m a straight man in the US and I’ve had a very conservative sex life up till now. I’ve only had sex with my ex-wife but this relation has ended.

Now I want to have protected sex (condoms) including unprotected cunnilingus on escorts. I wonder about the risks for HIV, Hep-B, Hep-C. Also, the various oral cancers associated with HPV-16 and 18 or other STDs. It seems like menstrual blood, cuts or bloody gums would be a high risk. Is menstrual blood different than other blood?

I really appreciate the risk assessments in terms of numerical probabilities and percentages I see in many of the answers that Doctors Hook and Handsfield can give. That would be most valuable and appreciated. And studies which document these risks would be invaluable too. I would like to be able to have answers that would help me evaluate all the (crazy?) information to the contrary that I see on the web. I need numbers to separate the wheat from the chaff.

Also, are there vaccinations or other precautions and things to do to lessen the risks?

Big Thanks,
Dean

H. Hunter Handsfield, MD

99 months ago

Welcome to the forum. I'll do my best to answer your questions, but for the most part precise numerical data do not exist. However, the sorts of exposures you describe will be low risk for all STDs.

Escorts -- by which I mean expensive female sex workers who usually work by appointments (as opposed to brothel workers, street or bar pickups, etc -- generally are considered low risk for STDs, probably safer than most casual but non-commercial sexually active women. Many escorts use condoms regularly, tend to have low risk clients (e.g. married or committed and mostly monogamous men), and get tested frequently. Second, properly used condoms are highly protective against STDs transmitted primarily through secretions (like gonorrhea, chlamydia, HIV, and viral hepatitis); but less effective against those transmitted skin to skin (like herpes, HPV and syphilis) (but even for these, far safer than using no condom at all).

Cunnilingus is a highly safe activity with very low risks for all STDs -- safe enough that most experts don't recommend barriers, even though you can easily find such recommendations on line (e.g. dental dams, plastic wrap, etc). Performing cunnilingus on escorts will put you at small risk for gonorrhea and in theory for oral herpes due to HSV2 -- but I've never seen a case of either of these. There would be a risk of syphilis, except that syphilis is vanishingly rare in such women.

Statistically, your greatest STD risk will be for HPV. Most of that risk will come from vaginal sex, despite condom protection (because of unavoidable skin contact above the condom), not from cunnilingus. Oral HPV can be acquired by oral sex, but the large majority of infections cause no symptoms and are cleared by the immune system. There is only a single oral cancer -- specifically, pharyngeal cancer -- caused by HPV, and that results almost entirely from a single HPV (16). Such cancers remain rare, despite all the publicity in recent years -- only about 10,000 cases per year nationwide. You may well die of cancer someday, but much more likely colon, prostate, lung, lymphoma, pancreas, and all the others much more common than pharyngeal. How frequently you do or don't have sex with escorts won't make any significant difference in your risk of pharyngeal. All in all, your risk for any significant health problem from HPV will be very low.

And anyway, that brings us to vaccines: You could be immunized against HPV, which will protect you against 9 of the most troublesome types, including the two that cause 90% of genital warts and the 7 types that cause 90% of cancers (including HPV16). Although it takes 3 doses of vaccine over 3 months for full protection, almost complete protection is present within a month after the second dose, i.e. 2 months after starting. You also could be vaccinated against hepaitits B, although your risk for it from the exposures you have described would be extremely low.

Numerical estimates for condom protected vaginal plus unprotected cunnilingus: these are mostly educated guesses, but per exposure I would say less than 1 in 1000 for all except HPV. One chance in several thousand for herpes. Zero for HIV and hep C (which contrarly to popular belief is almost never heterosexually transmitted) and nearly zero for hep B. No risk for chlamydia. All these risks would rise in event of condom failure but still the odds would be strongly in your favor.

I hope this has been helpful. Let me know if anything isn't clear.

HHH, MD

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H. Hunter Handsfield, MD

99 months ago

Correcting a potentially important typo above: The HPV vaccine requires 3 doses over 6 months, not 3. But still protection is nearly complete after the first 2 doses. (It is possible that in the not too distant future CDC and/or other agencies will advise that 2 dose regimens are sufficient.)

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99 months ago

Dr. Handsfield,

Thank You for your quick, thoughtful and comprehensive reply. Your thoughts on escorts are what I thought.

I still have worries about five things; one thing with menstrual blood and four things with pharyngeal cancer:

1. I don’t know how menstrual blood doesn’t pose a risk for HIV and Hep-C. I suppose blood is just another bodily fluid as far as risk is concerned. If that’s right, then I’m persuaded.

2. Next is pharyngeal, which is the one that scares me the most because it can kill you unlike warts which can’t. I’ve read that pharyngeal cancer is quite hard to detect and treat.

3. Also, it seems like I would very likely acquire HPV-16 from unprotected cunnilingus. You say “How frequently you do or don't have sex with escorts won't make any significant difference in your risk of pharyngeal”. Is that because any one who performs cunnilingus is sure to acquire HPV-16 in the first few episodes and any subsequent exposure would pose no additional risk?

4. And I’ve read about doubts/unknowns about the effectiveness of Gardasil in immunizing against HPV-16. How bullet-proof do you think I would be if I was vaccinated?

5. I’ve had the first dose of Gardasil-9 about 10 months ago but stopped after I got a bill for $469 for each dose (I’m over 26 years old and so I would need to find a less expensive clinic) and after I had some headaches (likely unrelated). If I continued now, do you think I could just continue with a second and third dose or would I have to start over from the beginning and get all three doses again?

The number (10,000 cases per year) is reassuring. I worry that they are all concentrated in men named Dean who visit escorts, i.e. distribution in the whole population isn’t even. If you know of any studies that break the distribution down, I would be extremely interested.

Thank you very much,
Dean

H. Hunter Handsfield, MD

99 months ago

1) Several research studies show that spouses and other regular sex partners of persons with hepatitis C virus have no higher risk of HCV themselves, even after several years or lifetimes of reguiar sex with one another -- after controlling for other HCV risks, like injection drug use with shared needles. It is logical to assume that sex during menstruation sometimes occurs, yet still no significant risk. The truth is that the ONLY proved, regular sexual transmission of HCV occurs in gay men who participate in potentially traumatic anal sex practices. Otherwise, HCV should not be considered an STD at all. I don't know that "blood is just another bodily fluid", but consistent condom use still would be protective. Also, for the same reasons, the chance an escort has HCV, if not an injection drug user, will be very low.

2) True, pharyngeal cancer can be difficult to detect. However, it remains rare, as your closing comment acknowledges. The only breakdown I know off hand is that most of those cases occur at age 50 and older, and are not necessarily more common in persons who do or do not frequently perform oral sex on their partners.

3) There are no data on the risk of HPV 16 (or any other type) for any particular oral sex exposure, but it's probably low. In the largest national study, there actually was NO correlation between oral HPV (including HPV16) detection and past history of oral sex. While oral sex is obviously one route of infection, many probably occur because of auto-inoculation from persons' own genital infections.

4) I am unaware of any reliable data to suggest Gardasil is not 100% effective against acquisition of HPV16.

5) I recommend getting two more doses of the vaccine. In view of your frankly inflated fears about HPV in general and HPV16 in particular, the additional cost will be small price to pay for the likely improved confidence it will give you. And depending on what you expect to spend on your escort appointments, perhaps only a small additional investment in these sexual adventures.

Cheers-- HHH, MD

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98 months ago

Dr. Handsfield,

Thank you again for your valuable reply. You mentioned several studies showing that HCV wasn’t a significant risk with the high probability of cunnilingus with menstrual blood. But how about HIV? If a man had bleeding guns or mouth sores and contacted menstrual blood during cunnilingus, that seems like a real risk for HIV. Isn’t that correct?

As you say, I believe my greatest risk is from HPV. I appreciate the perspective you have given me on this but I would really love to be able to quantify the risk and get a firm perspective for these infections as much as possible. So please tell me what that large national study you mentioned is, that shows no correlation between history of oral sex and oral HPV.

I did find a couple of things on the web saying a greater number of sex partners increases the risk of HPV-16 infection. One was a talk and study by Dr. Maura Gillison PhD. (JAMA. 2012;307(7):693) (http://www.ncbi.nlm.nih.gov/pubmed/22282321) and the other was an Oral Cancer Foundation (http://oralcancerfoundation.org/hpv/hpv-oral-cancer-facts.php) page. I think there is a similar statement on a CDC site but I can’t seem to find it now. Conclusions weren’t as straight forward as I would have liked and I’m not confident that I’m evaluating these things well.

Also, I’m already over 50, the age when this type of cancer starts to show up.

I agree that the number of oral infections caused by HPV is very low as a percent of the US population, but it seems like there is a much greater risk for men who perform cunnilingus on escorts. I’m interested in that large national study you mention and in any additional thoughts on HPV-16/pharyngeal risk please.

Thank you again for your time and very valuable responses,

Dean

H. Hunter Handsfield, MD

98 months ago

There are no proved cases of HIV transmission by cunnilingus, and obviously there must have been billions of such exposures, undoubtedly many of them in the presence of menstrual blood. In general, HIV infection via the oral cavity is rare.

Sorry, there is no way to quantify the risk of HPV. You have already cited the research paper I was referring to. Also see the letter to JAMA that I wrote in response to an editorial that accompanied it. http://www.ncbi.nlm.nih.gov/pubmed/22618914

Being age 50, you also are at much lower risk than younger people for new HPV infections, regardless of your sexual lifestyle. The biologic reasons for lower risk aren't entirely understood, but they are partly due to previous infections when younger, making people immune (or at least resistant) to reinfection with those types. That's why HPV immunization is not recommended beyond age 26. Any risk you might have for pharyngeal cancer someday is more likely related to past infections with HPV 16, not from ones still to come. Anyway, although the frequency of pharyngeal cancer has risen in recent years, it remains rare compared with the others that kill people far more commonly, like colon, lung, prostate, etc. There is no reason to suppose that "there is much greater risk for men who perform cunnilingus on escorts". But if you remain so worried about it, I would just suggest you not participate in that activity, or do it only with barriers like plastic wrap. (You'll see in my JAMA letter that I said barriers in general need not be recommended in order to prevent pharyngeal cancer due to HPV 16. But don't confuse contexts: that statement means that general advice for to public to use of barriers probably would not prevent many such cancers. But undoubtedly consistently used barriers would further reduce the already low chance of oral HPV from cunnilingus.)

That completes the two follow-up comments and replies included with each forum question, and so ends this thread. I hope the discussion has been helpful.

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